Torticollis

Torticollis

Torticollis means "twisted neck" in Latin. When it occurs in newborns- whether due to positioning in the womb, after a difficult childbirth or other factors- it is called infant torticollis or congenital muscular torticollis (CMT). Usually, there is no pain with CMT; however, treatment is crucial in order to avoid motor development delays, postural deficits or craniofacial deformities. Note: There are other forms of torticollis, also known as dystonia. This is quite different than Infant Torticollis.

CMT is relatively common in newborns, either being present at birth or developing in the first three months. Estimates are that one in 250 babies develop the condition. No one knows exactly why some babies develop CMT while others don't. Most doctors believe it could be related to cramping of the fetus in the uterus, muscle trauma during delivery, some sort of soft tissue compression, and/or congenital abnormalities of soft tissue differentiation. It may affect firstborn children, twins or very big babies more often, because of the greater likelihood of too little space, or “crowding,” in the uterus and birth canal There has been some suggestion that the condition is increasing as a result of more multiple births and implementation of the "Back to Sleeping" positioning recommendations that decrease the risk of sudden infant death syndrome.

Whatever the mechanism, the result is tightness of baby's sternocleidomastoid muscle (SCM) — the large, rope-like muscle that runs on both sides of the neck from the back of the ears to the collarbone. Tightness on one side of this muscle can make it difficult for a baby to turn his or her neck. Some babies with torticollis also have developmental dysplasia of the hip, another condition caused by abnormal positioning in the womb or a difficult childbirth.

The diagnosis of torticollis is usually made by the pediatrician in the first 2 or 3 months of life when abnormal head posture, restricted cervical range of movement, or plagiocephaly (flattening of head) is noted during a "well baby" visit. Plagiocephaly is reported as a co-existing in 80-90% of CMT cases.

The good news is that CMT usually gets better if re-posturing and stretching exercises are started in the first year. Typically, children with less than 10° difference in range of cervical rotation between sides can be managed with home care. Those who don't respond to home treatment or have more limited rotation are referred to physical therapy. Positive outcomes in response to conservative treatment range from 70-90%. More aggressive treatments for resistant conditions include botox injections, the use of orthoses or surgery.

The restrictions and imbalances in the cervical muscles associated with CMT can lead to asymmetry of motor development and thus influence acquisition of motor skills. In addition, the adaptive compensations of the musculoskeletal system in the head, trunk and upper extremities can contribute to cranio-facial deformities, abnormal movements and compromised posture. The sooner physical therapy is started, the less likely more aggressive treatment or surgery will be needed.

In the physical therapy clinic, treatment of the infant with CMT is guided by the age of the infant, the severity of the torticollis, the ability/availability of the parents or caretakers to perform the exercises, the diagnosis of plagiocephaly, and the presence of associated neuromuscular or orthopedic impairments. Goals typically include:

  1. age-appropriate active and passive range of motion of cervical and trunk movement;
  2. prevention of contractures or further loss of movement in infants with significant fibrosis;
  3. symmetry of shape in the face, head, and neck;
  4. development of postural responses in all directions;
  5. centered upright posture of the head and neck without persistent tilt to the involved side; and
  6. symmetry of gross motor patterns throughout development.

Physical therapy will start with a detailed assessment of the infant and interview with the family. Based on this information, the therapist will design and implement a management program that will include activities in the clinic as well as at home. The home program should be incorporated into the family's routines and include: ways to handle, feed, carry, and position the baby; activities to encourage midline head and trunk postures; and gentle active and/or passive cervical range-of-motion exercises opposite to the torticollis posture and away from the plagiocephalic, flattened side. Parental and/or caretaker involvement is absolutely crucial for successful outcomes.

Manual stretching is by far the most common form of treatment for CMT; it is governed by two important considerations. The first is that it must not be painful for the infant. The second is that it can be replicated by the parents or caregivers. Ultimately, the severity of the torticollis, the age of the child, the tolerance of the child, and the parent's ability to carry out the exercise program will determine the method of stretching.

Stretching is often augmented with manual therapy, sometimes referred to as soft tissue mobilization. Here the therapist works the tight neck muscles and subcutaneous tissues by hand to release restrictions and increase pain-free range of motion. Joint mobilization, myofascial release, and craniosacral therapies are other manual techniques that may be used based on the therapist's skills and judgment. In some cases, therapeutic taping with kinesio-tape is used to stabilize weak and overstretched muscles.

In the home, stretching and strengthening exercises can be carried out through holding, carrying, and playing with the baby in postures and positions selected to achieve the desired active and passive movements. Strengthening overstretched muscles on the side opposite to the torticollis can be accomplished by guiding postural reactions as the infant matures to facilitate better control of the head and trunk.

Guidelines for discharge from physical therapy and for monitoring after discharge tend to be open-ended. This is to account for the fact CMT symptoms can re-occur during periods of growth as well as during periods of illness, teething, and acquisition of new motor functions. The therapy treatment plan will thus advise appropriate follow-up with the pediatrician and physical therapist.

If you think your child may have torticollis please contact your pediatrician or physical therapist.